Healthcare Provider Details

I. General information

NPI: 1053084343
Provider Name (Legal Business Name): JACQUELIN ESCOTO BENITEZ OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2021
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 LILLY RD NE
OLYMPIA WA
98506-5030
US

IV. Provider business mailing address

7619 RUSHMORE WAY NE
LACEY WA
98516-1340
US

V. Phone/Fax

Practice location:
  • Phone: 360-923-4333
  • Fax: 360-456-3894
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10219T
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD61291177
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: